RAC: How Good Samaritan Hospital RAC: How Good Samaritan Hospital Medical CenterMedical Center

Achieved a High Success Rate on Achieved a High Success Rate on AppealsAppeals

Lisa Krumpter RN, MSLisa Krumpter RN, MSAppeals Manager/RAC LiaisonAppeals Manager/RAC Liaison

Good Samaritan Hospital Medical CenterGood Samaritan Hospital Medical Center

Good Samaritan Hospital Medical CenterGood Samaritan Hospital Medical Center

A Member of Catholic Health Services A Member of Catholic Health Services of Long Island of Long Island

A High Acuity High Occupancy A High Acuity High Occupancy Community Teaching Hospital with Community Teaching Hospital with

437 Beds 437 Beds

8600 Medicare discharges in 20088600 Medicare discharges in 2008

Medical Necessity DenialsMedical Necessity DenialsGood Samaritan Hospital Good Samaritan Hospital Medical CenterMedical Center

TotalTotal

# of Medical Necessity Denials# of Medical Necessity Denials

No AppealNo Appeal

113113

88

# of Appeals at 1# of Appeals at 1stst Level (F.I.) Level (F.I.)

UpheldUpheld

OverturnedOverturned

105105

2828

7777

# of Appeals at 2# of Appeals at 2ndnd Level (QIC) Level (QIC)

UpheldUpheld

OverturnedOverturned

2828

2323

55

Medical Necessity Denials Medical Necessity Denials (cont’d)(cont’d)

# of Appeals at 3# of Appeals at 3rdrd Level (ALJ) Level (ALJ)

UpheldUpheld

OverturnedOverturned

2323

44

1919

# of Appeals at 4# of Appeals at 4thth Level (MAC) Level (MAC)

UpheldUpheld

PendingPending

44

33

11

Overall Medical Necessity Win Overall Medical Necessity Win RateRate

88%88%

Appeal StrategiesAppeal Strategies

Experienced Denial Management TeamExperienced Denial Management Team

Partnering with PhysiciansPartnering with Physicians

Database ManagementDatabase Management

Building a Successful Appeals TeamBuilding a Successful Appeals Team

Hire the Right People for the Right JobHire the Right People for the Right Job

Building a Successful Appeals TeamBuilding a Successful Appeals Team

Appeal NursesAppeal Nurses::

Strong Clinical Experience Strong Clinical Experience Knowledge of Insurance and/or Hospital Case Knowledge of Insurance and/or Hospital Case ManagementManagementGood Organizational SkillsGood Organizational SkillsGreat Critical Thinking SkillsGreat Critical Thinking SkillsHighly Motivated to Meet DeadlinesHighly Motivated to Meet DeadlinesStrong Analytical Skills Strong Analytical Skills Ability to Work in a Team AtmosphereAbility to Work in a Team AtmosphereEfficient Computer SkillsEfficient Computer Skills

Building a Successful Appeals TeamBuilding a Successful Appeals TeamPhysician Advisors:Physician Advisors:

Excellent Interpersonal SkillsExcellent Interpersonal SkillsClear & Concise Written SkillsClear & Concise Written SkillsStrong Clinical ExperienceStrong Clinical ExperienceGood Organizational SkillsGood Organizational SkillsUrgency to Meet DeadlinesUrgency to Meet DeadlinesUnderstands Denial DataUnderstands Denial DataAbility to Work in a Team AtmosphereAbility to Work in a Team AtmosphereComputer SkillsComputer SkillsParticipates in UM CommitteeParticipates in UM CommitteeOngoing Communication with Peers Internally/ExternallyOngoing Communication with Peers Internally/ExternallyEducation of Attending PhysiciansEducation of Attending Physicians

Building a Successful Appeals TeamBuilding a Successful Appeals Team

Appeals Support Staff:Appeals Support Staff:

Insurance and/or Hospital/Medical ExperienceInsurance and/or Hospital/Medical Experience

Detail-Oriented and Strong Organizational SkillsDetail-Oriented and Strong Organizational Skills

Up-to-Date Computer SkillsUp-to-Date Computer Skills

Good Interpersonal/Communication SkillsGood Interpersonal/Communication Skills

Ability to Work in a Team AtmosphereAbility to Work in a Team Atmosphere

How We Decide What to AppealHow We Decide What to Appeal

Daily MeetingDaily Meeting::Denial Management Team meets to discuss all new Denial Management Team meets to discuss all new denials denials

Team members include:Team members include:– Appeals TeamAppeals Team– Physician AdvisorsPhysician Advisors– Care Management DirectorsCare Management Directors– Corporate Denials TeamCorporate Denials Team– Social Work SupervisorSocial Work Supervisor– Business Office RepresentativesBusiness Office Representatives

How We Decide What to Appeal How We Decide What to Appeal (Cont’d)(Cont’d)

All RAC denials are reviewed by the Denials All RAC denials are reviewed by the Denials Management Team to establish that Medicare guidelines Management Team to establish that Medicare guidelines for inpatient care were metfor inpatient care were met

Previously appealed RAC denials are discussed to Previously appealed RAC denials are discussed to determine the next appropriate course of actiondetermine the next appropriate course of action

The AppealThe Appeal

Time is of the Essence: All Denials are Appealed Time is of the Essence: All Denials are Appealed Within the Required TimeframesWithin the Required Timeframes

Diligent Follow-up and Communication Are Diligent Follow-up and Communication Are Essential Throughout All Levels of the Appeal Essential Throughout All Levels of the Appeal ProcessProcess

All Appeals From QIC Level & Above are Written All Appeals From QIC Level & Above are Written with the Physician Advisor and the Attending with the Physician Advisor and the Attending PhysicianPhysician

Physician Advisor and Attending Physician Actively Physician Advisor and Attending Physician Actively Participate in All ALJ HearingsParticipate in All ALJ Hearings

Database ManagementDatabase Management

Maintaining the Database is Critical to Maintaining the Database is Critical to Ensure that Timeframes for the Appeals Ensure that Timeframes for the Appeals are Metare Met

The RAC Database Allows Reporting of The RAC Database Allows Reporting of How the Hospital is Impacted Financially.How the Hospital is Impacted Financially.

Denial Reasons are Tracked and TrendedDenial Reasons are Tracked and Trended

Case ExampleCase Example82 Year old male admitted for Elective Implanted 82 Year old male admitted for Elective Implanted

Defibrillator Defibrillator

Complex medical history included:Complex medical history included:– NYS Class III Congestive Heart FailureNYS Class III Congestive Heart Failure– Prior Myocardial InfarctionPrior Myocardial Infarction– Ischemic CardiomyopathyIschemic Cardiomyopathy– Left Ventricular Systolic DysfunctionLeft Ventricular Systolic Dysfunction

FI/QI Level was Denied with Rationale: “The management FI/QI Level was Denied with Rationale: “The management received was appropriate but did not rise to the level of received was appropriate but did not rise to the level of inpatient.”inpatient.”

Case Example Case Example (Cont’d(Cont’d))ALJ Level of Appeal: Reversed DenialALJ Level of Appeal: Reversed Denial

How We Won the AppealHow We Won the AppealThe Comprehensive Brief was submitted two weeks prior to the The Comprehensive Brief was submitted two weeks prior to the hearing (reiteration of medical record). Highlighted exhibits from the hearing (reiteration of medical record). Highlighted exhibits from the chart were included with the brief:chart were included with the brief:– Documentation of Evidence Based Practice i.e.. LiteratureDocumentation of Evidence Based Practice i.e.. Literature– ASA ClassASA Class– Nurse Safety SheetNurse Safety Sheet– History & Physical from the CardiologistHistory & Physical from the Cardiologist– Denial Letter from QICDenial Letter from QIC– Morbidity Rate for the ProcedureMorbidity Rate for the Procedure

The Interventional Radiologist and the Physician Advisor attended The Interventional Radiologist and the Physician Advisor attended the hearingthe hearing– They presented a concise presentation of what was in the brief They presented a concise presentation of what was in the brief

and answered all of the questions asked by the judgeand answered all of the questions asked by the judge

QUESTIONS?QUESTIONS?